GW1-2021-05797_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. l v
4448A
a. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a livable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name .1 ft. ft. 65/8 in. .188 G.STEEL
' �� '��� 16.INNER SING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): H. ft. in.
Water Supply Well: 17.SCREEN
FROM 'I'O DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) tt. ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
_,)Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft• 20 ft PORT.CEMENT POUR
:)Monitoring DRecovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e,grain sim,etc.)
��}} n O
4.Date Well(s)Completed: _g _d.( Well ID# ft. a ft.
Sa.Well Location:
ft. ft.
Facility/Owu Name Facility ID#(if applicable) ft. ft.
'7?W N N G 16 H W U tt. ft.
ft.
Physical Address,City,and Zip ft. j
[A"C AC�Q/t�)t -7 f�f/ 21.REMARKS qIng Old
i✓_ �rtf�rr ,a County Parcel Identification No.(PiN) WAR ser-111",
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certifi o
3yiq-aa N loll 10f-34S W
6.is(are)the well(s) Permanent or OTempOrary Signa ofCcrtificd well Contractor Date
By signing this form, i herebv certify that the well(.$) was(were)constructed in accordance
7.is this a repair to an existing well: Oyes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(ixample-3@20 an/d�2@100') construction to the following:
10.Static water level below top of casing: K� (ft.) Division of Water Resources,information Processing Unit,
if water level is above casing,use'•+- 1617 Mail Service Cetiter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of this';form within 30 days of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit':one copy of this form within 30 days of
13b.Disinfection type: HTH Amount:z�iz 3 completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016